In 2010 the European Society of Cardiology together with the European Association for Cardio-thoracic Surgery issued their joint guideline on Coronary Artery Bypass Surgery (CABG) and Percutaneous Coronary Intervention (PCI commonly called balloon angioplasty/stent).
The European guidelines are are in almost complete agreement with the 2011 American Heart Association guidelines. However, I think that the European guideline is easier to follow and easier to use for decision-making.
The ESC/EACTS “Guidelines on Myocardial Revascularization” are available at: https://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-revasc-FT.pdf.
Here’s a brief look at some of the topics covered in the European Guidelines.
Coronary artery disease means cholesterol buildup inside the heart arteries. This buildup can be severe enough to decrease blood flow to the heart muscle causing possibly chest pain, heart muscle damage, and death.
There are three ways to treat serious coronary artery disease/cholesterol buildup (CAD).
1. We can bypass the area of cholesterol buildup with coronary artery bypass graft surgery (CABG).
2. We can perform a percutaneous coronary intervention (PCI meaning angioplasty/stent) to try to dilate or open up the area of cholesterol buildup.
3. And finally, we can treat the cholesterol buildup with medicines such as statins (to reduce cholesterol blood levels), blood pressure medicine, ACE inhibitors, beta blockers, nitrates other medicines, and healthy living habits (healthy diet, daily exercise, and no smoking). The guidelines call this treatment Optimal Medical Therapy (OMT).
And there are two reasons why we treat coronary artery disease.
1.The first reason to treat is to help people live longer, to prevent premature death from heart damage caused by severe coronary artery disease.
2.The second reason to treat coronary artery disease is to help people live better, that is, to prevent symptoms like chest pain (angina) that interfere with a person’s ability to enjoy life.
And there are three situations in which we need to decide what treatment to use. And these three situations are:
1. Stable Ischemic Heart Disease (SIHD)
2. Acute Coronary Syndrome without ST-segment elevation (Non-STEMI-ACS)
3. Acute Coronary Syndrome with ST-segment elevation (STEMI-ACS),
And finally there are two aspects of each possible treatment that we need to consider:
1. What are the risks of death or other complications from the proposed treatment (CABG, PCI, and/or OMT?
2. What are the likelihood of benefits from the proposed treatment (improved survival and/or improved symptoms [improved quality of life])?
So for each different situation (SIHD, STEMI-ACS, Non-STEMI-ACS) we need to decide the best method of treatment (CABG, PCI, and/or OMT) based on the patient’s informed choice.
And for each different situation we need to decide the purpose of the treatment (to help the patient live longer or to help the patient live better.
And finally in each different situation (SIHD, STEMI-ACS, Non-STEMI-ACS) we need to estimate the risks versus the benefits of each of three possible treatments so the patient can make the choice that best fits his values.
In upcoming posts, I will discuss treatment decision making for each of the three situations using the recommendations of the European guidelines.